Designing with Patient & Provider EHR Workflow in Mind: My Conversation with AdvancedMD

Every once in a while I get to have a really, really meaty conversation about healthcare workflow. I’m especially interested in so-called “front-end” workflows, the ones most directly affecting (one might actually more accurately say “effecting”) provider and patient experience. So I was especially excited to sit down with Jared Alviso, PMI-ACP, Senior Product Manager at AdvancedMD, to discuss the shift in the company’s mindset toward designing workflow- and process-aware healthcare technology.

By the way, this is a hectic week for AdvancedMD, they’re at three conferences!

Plus I, myself, am an eHealth Week Social Media Ambassador at the eHealthWeek conference on Malta (#eHealthWeek on Twitter).

(I’m tempted to put an animated GIF referencing the admonishment in Ghost Busters, to not “cross the streams,” but … oh what the heck!)

All in all, this week is an incredible conjunction of opportunities to press that same case I’ve now been making for decades. Healthcare needs to dramatically up its game when it comes to improving workflows to improve patient and provider experience!

Let’s found out from Jared about AdvancedMD’s advanced thinking about front-end healthcare workflows.

1. CW: What is “integrated workflow” at AdvancedMD?

JA: Our client base at this time is a smaller private practice. In that practice, a medical assistant could also be the front-office person taking phone calls and making appointments. One thing we are looking to do is put the practice management features and functionality needed to fully run an office into the EHR. We know that most EMRs/EHRs are all about the clinician side of things, so from an integration perspective, we put some of the key [practice management] workflows and functions into the EHR. A medical assistant can now take care of appointment scheduling and track the charge slips from the EHR itself in visible day-to-day appointment workflows.

The first step we’ve taken is with our new AdvancedEHR dashboard. The dashboard basically allows our clients to see a single column scheduler – a list-view of the patients they’re seeing that day. Additionally, it allows them to see non-appointment workflow items. When they’re not seeing patients, they’re actually looking at messages, pending referral requests, pending lab orders, result orders – in other words, items that need to be addressed that are not necessarily associated with an appointment, and the dashboard allows them to do that.

CW: Is it live in the sense that if you don’t touch it and you just look at it, you see things happening?

JA: Yes, it is live. If you were to just leave the dashboard there, here is what happens. As you check in the patient, you “flow” with the patient, you’re able to see that the dashboard actively updates, as well as any new messages and any new review bin or task items that come across to the user that’s logged in.

CW: Are there some kind of workflow rules behind the dashboard?

JA: That’s the case. We are making the dashboard customizable based on the workflows for that individual practice. We want to make it specialty-specific and workflow-specific out of the box. If a user has rights to see certain providers’ schedules, they will in return see the potential review bin or task that needs to be done. We know that an orthopedic doctor is not going to want to see immunizations and growth charts. Donut graphs that we currently have in the dashboard are customizable, and you can drag and drop items in a view that best suits the user.

CW: Is there a sort of an editor mode – just like you would author a report? You’re authoring or editing the dashboard view.

JA: To the extent as it relates directly to the dashboard graphs themselves, yes. You would enter into an edit mode, then drag and drop things wherever you would like to place them. And the table would directly reflect whatever changes you made. To further elaborate on that, we also are adding a filter functionality, which is going to allow users to see their review bin items, such as results review and prescription renewals. Or, they can filter to see a specific provider information should they have access to do so.

CW: What is a quick list of systems with which you integrate?

JA: Areas that we’re looking to integrate into the workflow are around patient engagement. We’ve added a rooming integration to be able to track the patient flow. That’s from our practice manager assistant to the EHR and all the way to our mobile application. We also have our patient messaging, communications that will be accessible from the dashboard in all of our platforms. They also have the ability to capture what patient preferences are – if they like to be communicated with via text or e-mail or phone, we can capture that information. We also have patient forms capture so the intake process is another key thing that can be monitored throughout all of our portfolio of applications.

2. CW: I think a good strategy for companies is to figure out how to use workflow, workflow-esque ideas and workflow thinking to market the advantages of a product. A) Do you agree? B) When and how did AdvancedMD realize that workflow is key?

From that perspective, I do agree. Now, you ask when AdvancedMD really realized the importance of workflow. From a historical perspective, AdvancedMD has at first been a practice management system. Workflow was obviously the reason for success of our practice management system. Since then, we’ve added the EHR. Today, we’re really trying to change the conversation here at AdvancedMD by indicating that flow is key. In the design phase, we’re going down the path of outright creating “certified workflows,” or we can call them “best practice workflows.” We basically say, “This is how AdvancedMD recommends you write a prescription, how you document your patient visit, how you order your labs, and how you preview your results and do your messages.” Everything we’re doing for the new design of AdvancedEHR is around the workflow definition first, so that we could help extract the requirements needed to run a successful practice. Then, we do not force the requirements into the design, but rather make the design suited to the business requirements and, in this case, the office workflow.

We feel that providing the “best practice workflows” is going to be key and that’s what we’re focusing on from a software development perspective. We know not every office is the same, but we do know that probably around 80% of practices are the same. We can do customization for the other 20%, such as specialty-specific things. That’s the big effort and we’re much vested in it.

3. CW: Do you have an example or can you paint a mental picture of how two different sub-systems such as the EHR and the practice management system, because of the similar look and feel, are going to give a better or more satisfying or more efficient or more effective user workflow experience?

JA: From the practice management perspective, we’ve made our application browser-agnostic, so it can be used in any browser, Chrome, Safari, Firefox, IE, anything. With that came a design of what we call the “new shell.” This new shell contains a menu structure that allows us to use the latest technologies as we create new software. As it relates, the design, the look, the feel, the functionality and the value that it brings to our clients is the ability to say, “You know what? It’s integrated. You don’t have to switch among multiple terminals or applications open at once. You can actually schedule an appointment from the EHR based off of your ‘persona’.”

The persona base is another big focus area for us. Based on your persona, what you see when you log in to the integrated application is what you’re going to get. If my role and persona in the office is receptionist, I’m going to get scheduling, I’m going to get access to very minimal patient information because I don’t need to see all the clinical information. Harvesting that information, and being able to do that from one application, to me, the value that it adds is like the alt-tabbing. Customers can now work within the structure that we built in the global shell, and be accustomed to the global feel of our practice management and EHR systems.

4. CW: One frequently hears EHRs are not usable because they were designed as billing systems. What does AdvancedMD respond to that?

JA: The way I feel we are responding to the needs of providers is by putting more emphasis on the clinical side of things. Billing is probably the number one thing that private practices are making sure they can achieve. But next to that, what’s the most important thing to clinicians? It is being able to document/back up claims that they’re making to insurance. So, having a good system that’s able to document that and a good process is key. We think persona-based system can address the issues that each role has in an ambulatory flow.

CW: Yes, when people think of electronic health records, they tend have a very data-centric notion. They think, well, an EHR is basically a database with a user interface on it. EHR matches the structure of the data, when you really need it to match the structure of the workflow. But if you have a system in which the workflows can be customized by person and role, you can have billing and clinical workflows existing in the same system. I’m giving my opinion here, and there’re a lot of EHRs out there that are designed, like you said, with billing being historically a number-one priority, and then of course, you have the clinical part of it. And if you can’t have different workflows for different roles and people – and I think that would be the personas in your case – then you’re going to butt heads. You’re going to have to go with the billing workflow. But if you can have customizable workflows for different people and roles and personas, then you can have your cake and eat it, too.

5. CW: Just how customizable are AdvancedMD’s workflows? What’s the basic workflow customization paradigm?

JA: One of our primary objectives for the integrated workflow project is for products to function fully right out of the box. We deliver the EHR already customized by a specific specialty; we have our core four: family practice, pediatrics, internal medicine and obstetrics. We can also open it up to a broader array of specialties.

So, out of the box functionality is priority number one. Number two is customizing specifically around how customers use the software. If there’s a tweak or two they want to make, they can actually do it on the fly. We have a huge matrix that allows them to pick—for example, if a user changes the layout of the [AdvancedEHR dashboard] donuts, the next time they log in, the donuts retain the new view. This is because they changed the look for a reason and we want the system to remember the preference. For example, AdvancedEHR today is very customizable. Users can go in and create templates for specific visits. They can create specific chart flows. If they feel like they’re not getting what they need to see in the summary, they can say, okay, I need to pull in, let’s say, an allergies card. They can go in and pull in a specific, new view element that allows them to see a patient’s allergy and they can do that on the fly.

To sum up, these are a few different approaches that we’re taking. One, we want the systems to be easily used by anybody out of the box. Two, somebody in the administrative role can go in and create custom views and then disperse them to users; and three, on an individual basis, a user can change and customize the views at will.

CW: I heard you mention the phrase ‘chart flow’ earlier. What do you mean by chart flow?

JA: The chart flow is different. There’re two main things that we’re focusing on. We have 1) non-appointment workflows and 2) appointment workflows. The chart flow is essentially going through and during the appointment workflow: from when a patient checks in, the nurse puts them in an exam room and gets all the subjective information and the provider wants to be able to access [the “rooming” information before the visit]. We are working on determining such flows. You know, the age-old conflict of somebody being in the chart while somebody else is in the chart. It can create potential data conflicts. Chart flow is something that we’re addressing not only from a data conflict point of view, but we are also making it possible to access a patient’s chart from basically anywhere.

A good example is, again, the AdvancedEHR dashboard. We have the ability to do multiple things on the single column scheduler. Customers can click through to where it opens up a patient chart, change the rooming status [showing details of a patient waiting in the exam room], check them in, check them out and put notes on the patient’s chart – all from a single column scheduler. That represents a small fraction of the chart flow. Because we put information on a scheduler card, it allows that data to flow to the chart.

6. CW: How “transparent” are AdvancedMD’s workflows? How easily can task status (pending, completed, escalating, etc.) be tracked?

JA: As far as tracking workflows, it goes back to our earlier discussion about seeing changes happen on the dashboard. For example, with the rooming module, a user can see not only the patient status and the exam room they’re in, they can also see that they are waiting for a nurse, or a provider, or for a lab tech to do a blood draw. We also track the time it takes so that the clinic and the office manager, someone from an administrator perspective, can identify bottlenecks in the workflows. So, if a patient is “sitting in a status” for a certain amount of time, visually, on the dashboard, the task item will turn red, indicating the threshold has been crossed. That would mean that the patient’s been waiting for the nurse for the past 15 mins.

The value here is to allow our clinics, our practices, to identify workflow bottlenecks from a day-to-day basis, and that’s just one example. Another example is receiving labs results or sending lab requests to be processed. As users navigate throughout AdvancedEHR, the dashboard is going to refresh every time they come back to it. We also use automated pop-up messages indicating things like priority messages. This is actually a new feature that we’ve enabled for all of our chart items within AdvancedEHR: users can set chart items as high priority. When it comes to interfaces with labs to receive results and send orders out, we’re designing automatic flags that are going to mark them as priority. Based on the way we have the dashboard configured, we have a priority bucket, we have a help bucket, and we have all other unsigned items. There are different quick drill-down capabilities for them to be notified quickly when something high-priority comes in.

7. CW: How smart are automated workflows? Does some new data, something that gets downloaded into the system, trigger a workflow to end up in the right place, to catch someone’s attention?

JA: Yes, that is something that exists today and we refer to as HealthWatcher [within the EHR]. There are rules that can be customized for specific practices and specialties. What HealthWatcher allows you to do is to set up specific rules based on, just as a quick example, a yearly physical. Users can set up lab orders and appointments based on gender, age or other criteria to automatically notify the physician or clinical staff that a particular person that they’ve selected or scheduling an appointment for is in need of these lab draws or a physical. These items are included as part of our customizable donut graphs or data that is displayed on the dashboard. Users can access the feature from the dashboard, which is what makes it automated.

8. CW: From a historical timeline, first, it was practice management system, then EHR, then patient engagement and telemedicine. What comes next? How will the new tools be integrated into existing, seamless, streamlined workflows?

JA: From a timeline perspective, we’re looking for some of the enhancements as well as integrations to be problem-based. We’re allowing the data that’s captured from a patient visit to be used to benefit the clinic. It is not about data telling the provider how they should be practicing medicine, but rather guiding them. It’s basically saying, “Based on how you diagnosed a patient with hypertension and diabetes in the past, here’re the prescriptions that you’ve written, here’re the notes that you used, here’re the images that you used, the labs that you ordered, and the plans that you’ve associated with these particular types of cases.” From a high-level design perspective, this is how we are looking to make that data work for us and for our clients. That’s probably one of the biggest things that is coming out with the integrated workflow project.

CW: How about wearables and things like that?

JA: When it comes to wearables and health records like HealthVault, we hear from our existing client base that they want this data to be integrated with electronic health records. AdvancedMD currently has a huge initiative where we focus on patient engagement, patient portal and patient-facing mobile applications. That gives patients the ability to leverage various health apps that they have on their devices and upload data to their portal, which in turn will integrate with our EHR and practice management system.

That initiative is huge for us because our clients really want to interface with these applications and apps. It’s important to the patient, it’s important to our clients, and I think that’s where the industry is going. In addition to that, we also need to integrate with [other devices’] hardware; for example, an automatic blood pressure cuff that a patient is using or other medical devices the practice wants to interface with and capture data from. So, the wearables initiative is in the forefront for us and we’ve been planning and designing our execution in that area.

CW: Are you starting to look at or already have a common workflow engine capability or is it still peer-to-peer?

To me, a part of what makes a successful EHR is being able to integrate with whatever technology the industry introduces. Our interface teams and interoperability teams specifically focus on doing lab and order interfaces, work on integrations with other PM systems and with other EHRs. Added to this effort is our work to integrate with wearables and medical devices. We are using a lot of in-house, peer-to-peer at this point in time, but we’re currently exploring the integration with a couple of third-party vendors that would allow us to quickly integrate. Eventually, we could leverage the third-party to become that one specific integration engine for us.

9. CW: Do you offer any workflow improvement consulting services? Any workflow analytics? (Cycle time, thru put, activity based costs, bottlenecks spotting, etc.)

JA: To answer the first question, we have a professional services partner that helps clients that may need some post-implementation support. The partner will help with things like documenting their patients inside of a note, writing prescriptions, or understanding the flow for ordering labs.

As far as workflow analytics is concerned, the good thing is that we audit everything we do and that allows us to put the data that we’re capturing to work. The way we extend this data to help our client base of smaller practices, two to four providers, is by allowing them to pull reports. Let’s say, we’re going to create a new report and it’s going to be called “patient check-in report.” It provides value by letting the office manager, or practice manager, know that, for example, our nurses are being kept up. Why? Is it the vital taking? Is it the note opening? Not only do we capture that data for reporting, we can also display it in the EHR dashboard to help with the clinical side of things.

CW: Well that’s truly impressive. You are moving away from what I call workflow-oblivious health IT, to process-aware. The idea is that IT needs to have some kind of awareness that there is such a thing as a workflow. Because if you don’t represent it, if it’s not a direct, explicit, intended workflow related behavior, you’re not going to get the various efficiencies and effectiveness and usability that a lot of people think is missing from a lot of health IT today.

Jared, do you have any words of wisdom or philosophizing you care to share as a closing remark?

JA: I have a passion for the new approach truly based around workflows. If we can’t expose the bottlenecks, the issues, the aches and pains that our clients and practices have on a day-to-day basis and make it easier for them to do their jobs, then we’re really missing the bus here. I agree wholeheartedly that being process-oriented and workflow-oriented is key. This mindset helps in all different avenues of business, not just software development.

CW: Viva la workflow and onward workflow-istas!


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